Transcript Assessing and Improving the Transfer of Patient Care

Assessing and Improving the Transfer
of Patient Care Responsibilities:
Implementing the 2006
JCAHO Patient Safety Goals
Vineet Arora, MD, MA
University of Chicago
Paul Barach, MD, MPH
University of Miami
Julie Johnson, MSPH, PhD
University of Chicago and
American Board of Medical Specialties
August 22, 2006
2:45 – 3:45
Objectives
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Understand safety of hand-off process and
new JCAHO requirements for hand-offs
Learn strategies for safe and effective handoffs from other industries
Review what we’ve learned about hand-offs
in clinical settings
Who’s in the audience?
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Physicians
Nurses
Pharmacists
Administrators
Social workers/Case managers
Other
Overview of Session
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Case presentation
“A Hand-off During the JCAHO Site Visit”
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Audience Poll
Hand-offs in clinical settings
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University of Miami experience
University of Chicago experience
Lessons learned from other industries
Final thoughts and recommendations
“A Hand-off During the
JCAHO Site Visit”
Debriefing from the Role Play
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What types of barriers to an effective hand-off
did you observe?
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Environment
Cultural
Communication
Any others?
What are the types of handoffs
that come to mind when you
think about handoffs?
How do you transfer care at your
institution?
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Do you have formal training on how to
perform hand-offs?
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Yes
No
Is verbal communication required for handoffs?
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Yes
No
Role of Hand-offs
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Exchange of vital information
Shared mental models and cognition of
patient status
Exchange and uptake of responsibility
Part of the microsystem life-cycle
Vital to Unit, patients, and workers survival
How can you learn about
hand-offs in your setting?
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Observational studies
Interviews
Surveys
Process analysis
Institutional Studies
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University of Miami
University of Chicago
The shift change study
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Behaviors, Attitudes, and Perceived Risks:
Communication of Patient Care Information Across
Shifts in Critical Care Settings
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Shift changes (handoffs, sign-outs) represent transitions
that can impact the quality of patient care and patient
safety
The literature dominated by the nursing profession
Little known about the factors related to shift changes in
health care that can undermine patient care
The shift change study
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Shift changes were investigated:
At three different sites:
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The PICU, PACU, and an adult patient ward
From three different perspectives:
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Ethnographic observations on nurses’ and residents’
behaviors and methods of communication
Structured interviews with nurse managers, attending
physicians, nurses, residents, fellows, and hospital
administrators on detailed attitudes and perceptions of risk
with regard to handoffs
A hospital-wide on-line questionnaire about general
attitudes and perceptions of risk related to handoffs
Sharit J, Thevenin, D, Barach P, Human Factors 2005.
Observational data
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Shifts 7am-7 pm
Expressed 30 min allotted for SO
24 observations, total of 85 hours, at different days of the
week and weekend
8 outgoing nurses, with at least 2 observations per nurse:
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2 occurred over 30-60 mins
3 occurred over 20-30 mins
6 occurred over 15-20 mins
6 occurred over 7-15 mins
7 occurred over 2-5 mins (28%)
Acuity of patients correlated to length of hand-off to some
degree but large overlap of duration of time
Full IRB obtained
Methods used to conduct
sign-outs
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Out of 24 observations
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Face-to-face communication was used in all cases (24/24)
Charts/handwritten materials were used in 23 cases
(23/24)
Monitors/equipment were referred to in 13 cases (13/24)
Electronic records, computers, or other providers were
never used (0/24)
Pointing to the patient occurred in 21 cases (21/24)
Touching the patient occurred in 5 cases (5/24)
Verbal communication with the patient or family never
occurred (0/24) despite open visiting hours
Behaviors of the nurses during
shift change reports
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Overall the outgoing nurses (OGNs) were
observed to be friendly and appeared willing
to share information with the incoming nurses
(ICNs)
The ICNs were generally not found to be too
inquisitive either in am or pm hand-offs
(qualitative scale of none-little-lot)
Interviews: Sign-out training
and evaluation
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No formal mechanisms are in place either for
instruction on how to perform sign-outs, or for
evaluating the sign-outs of nurses
Senior nurses, >15 years on job, 25-45 min
structured interviews
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Nurse Manager (NM)#1: “Nurses are so individualized and
patients are so individualized—it would be difficult (but not
impossible) to standardize the process”
NM#2: “You buddy up with a senior nurse for a finite period
and learn from that nurse what should be communicated to
the next shift”
Example 1: How ineffective
sign-outs can compromise care
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Omission in communication (NM#1)
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OGN fails to communicate to ICN that patient is
going to have a MRI that morning
ICN does not follow through to ensure MRI is
obtained
Patient's treatment delayed due to poor
scheduling with no back up system beyond the
hand-off request
Example 2: How sign-outs can
compromise patient care
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False assumption due to ambiguity in
communication leading to missed urgency
(NM#2)
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OGN indicates “I had some trouble with this port”
ICN assumes, based on the nature of the
communication, that the port was still flushing
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“After hooking everything up it didn’t work and I
needed to get meds in”
“I should have asked more questions”
Example #3: Perceptions on role
of technology
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NM#1
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“Written (electronic) notes are subject to interpretation”
“You can’t just read and interpret—you need to integrate
verbal report with visual cues”
Computerized charting would be helpful, make checking of
orders and calculations easier, aid documentation and
leave more time for touch and feel
NM#2
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“Face-to-face communication is essential”
Computerized charting would increase legibility, expedite
the process and keep nurses at the bedside
Example 4: The relative roles of
cultural background, personality,
and experience level in sign-outs
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NM#1: “Most of these critical care nurses are cut
from the same mold” (and rise above these
factors)
NM#2: “Personality and experience are influential
factors”, and “not cultural”
NM #2 “Inexperienced nurses need to be guided
on how to ask veteran nurses…”
Example 5: Conceptualizations of
ideal sign-outs
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NM#1: “No distractions, thorough review of
the patient's parameters, overview of how
patient did [that night], and then focusing
on “visualizing the patient” to ensure IVs,
fluids, drips are correct, side-rails are up,
ID band is on”
Example 6: Conceptualizations of
ideal sign-outs (SO)
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NM#2: “Stand next to what the issues involve,
“touching and poking”
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“Stop at each point, look at it, then go to face-to-face [with
nurse]”
“Doctor’s orders should be removed from SO and done
after” (saving 15-20 minutes at times)
“As an ICN, familiarity with the OGN, experience of the
OGN, and familiarity with patient should dictate how you
prioritize the SO”
University of Chicago
Experience
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Internal Medicine Department Study
Development and Implementation of
Standard Protocols
Critical Incident Study of
IM Hand-offs
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To characterize communication failures during handoffs and solicit suggestions for improvement
Question designed to elicit information about adverse events and near misses
Was there anything bad that happened or almost happened last night
because the (VERBAL/WRITTEN) sign-out wasn't as good as it could have been?
Question designed to elicit information about ideas for improvement
Regardless of whether anything went wrong or almost went wrong, and thinking about
what should be included in a sign-out, is there anything about the (VERBAL/WRITTEN)
sign-out that you received that you think should have been better?
Arora, Johnson, et al. Quality and Safety in Healthcare, 2005.
Developing a Model for
a Standard Protocol
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Principles underlying the model
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PROCESS
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Create a standard check-list
IMPLEMENTATION
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Create a process map
CONTENT
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The hand-off protocol will need to be discipline specific
Standardization is key for both process and content
Leadership and resident buy-in
MONITORING
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Ensure the protocol is in place and identify and resolve
barriers
A Sample Hand-off Process
(Internal Medicine)
Primary intern revises
written sign out with
emphasis on updating and
adding new information
Primary intern
goes to location of
covering intern for
meeting
Primary intern pages
covering (on-call)
Intern for sign out
Covering intern answers
page and sets meeting time
(sign out takes precedence
over other activities)
Primary intern verbally summarizes status of
patients on list, with focus on what needs to be
done, anticipated complications. There is a
standard language
Covering intern reviews and asks
questions for additional clarification
(may use read-back technique) as
long as needed
Primary Intern
forwards pager to
covering intern, via
pager system
Determine the Standard Content: ANTICipate
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Develop a
checklist
Have
disciplines
customize to
their needs
Can be used
to evaluate
the quality of
hand-offs
Administrative Data
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Patient name, age, gender
Medical record number
Room number
Admission date
Primary inpatient medical team, primary care physician
Family contact information
New Information (Clinical Update)
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Chief complaint, brief HPI, and diagnosis (or differential diagnosis)
Updated list of medications with doses, updated allergies
Updated, brief assessment by system/problem, with dates
Current “baseline” status (e.g., mental status, cardiopulmonary, vital signs,
especially if abnormal but stable)
□ Recent procedures and significant events
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Tasks (What needs to be done)
□ Specific, using “if-then” statements
□ Prepare cross-coverage (e.g., patient consent for blood transfusion)
□ Warn of incoming information (e.g., study results, consultant recommendations),
and what action, if any, needs to be taken that night
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Illness
□ Is the patient sick?
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Contingency Planning / Code Status
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What may go wrong and what to do about it
What has or hasn’t worked before (e.g., responds to 40mg IV furosemide)
Difficult family or psychosocial situations
Code status, especially recent changes or family discussions
Results
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To date, 8 residency programs have
participated.
Analysis of these protocols demonstrates that
the hand-off process is highly variable and
discipline-specific.
Process and content analysis of protocols
yields several themes.
1. Understand and attempt to
reduce the variation in the process
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All disciplines “required” a verbal hand-off
BUT due to competing demands (OR, clinic, etc.),
this verbal communication sometimes did not occur
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Educate residents on this important priority
Individual-level variation also present
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“Some residents are better at making
themselves available and touching base with
you [during the hand-off] than others...”
2. Hand-off = Transfer of information +
professional responsibility
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Transfers were at times separated in time
and space
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In one program, departing residents forward their
pager to the on-call resident after they provide a
verbal hand-off.
In another program, the on-call resident transfers
a virtual pager to their own pager at a designated
time which often occurs well before they receive a
verbal hand-off.
3. Need to ensure “closedloop” hand-off communication
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In two cases, patient tasks were divided and
assigned to other team members
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To facilitate early departure of a post-call resident
(to meet resident duty hour restrictions)
BUT results of these tasks were not formally
communicated to anyone
Residents ensured “closed-loop”
communication by building required follow-up
on these tasks into the process
Lessons from Other Industries
and Applications to Healthcare
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Lessons learned from other high-risk
industries
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Strategies for effective hand-offs
Applications to healthcare
Recent focus in healthcare
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ACGME duty hours
JCAHO National Patient Safety Goal
Hand-off as a Form of Communication
“When you move from right to
left, you lose richness, such as
physical proximity and the
conscious and subconscious clues.
You also lose the ability to
communicate through techniques
other than words such as gestures
and facial expressions. The ability
to change vocal inflection and
timing to emphasize what you
mean is also lost…Finally, the
ability to answer questions in real
time, are important because
questions provide insight into how
well the information is being
understood by the listener.”
–Alistair Cockburn
Hand-offs in Other
High-Risk Industries
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Direct observations of hand-offs at NASA, 2
Canadian nuclear power plants, a railroad dispatch
center, and an ambulance dispatch center
STRATEGIES
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Standardize - use same order or template
Update information
Limit interruptions
Face to face verbal update
 with interactive questioning
Structure
 Read-back to ensure accuracy
Patterson, Roth, Woods, et al. Intl J Quality Health Care, 2004
Applications of Standard
Language
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“Read-back”
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Reduces errors in lab reporting
“Read-backs” at your
neighborhood Drive-Thru
29 errors detected during
requested read-back of 822
lab results at Northwestern
Memorial Hospital. All errors
detected and corrected.
Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004.
A Word of Caution on
Technology
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Computerized sign-out
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Brigham and Women’s Hospital
(Petersen, et al. Jt Comm J Qual Improv, 1998)
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U Washington
(Van Eaton, et al. J Am Coll Surg, 2005)
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IT solutions alone cannot substitute for a
“successful communication act”
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Human vigilance still required
In an emergency room, replacing a phone call for critical lab
values with electronic reporting with no verbal communication
resulted in 45% (1443/3228) of urgent labs to go unchecked.
Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, 2001.
Recent Focus on Hand-offs
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July 2003– ACGME set limits for
resident duty hours
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Reduce sleep deprivation and
improve patient safety
Unintended consequence is
increase in number of hand-offs
(discontinuity)
Safety of hand-off?
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Error-prone and variable
A vulnerable “gap” in patient care
The Role of the Hand-off:
Communication and Patient Safety
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Transfer of information
(content)
Different modalities
(process)
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Written
Verbal
Variable, error-prone
Few trainees receive formal
education
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New JCAHO National
Patient Safety Goal
(effective Jan 1, 2006)
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“Requires hospitals to
implement a
standardized approach
to hand-off
communications and
provide an opportunity
for staff to ask and
respond to questions
about a patient's care”
Final Thoughts and
Recommendations
The ‘Swiss cheese’ model of
organisational accidents
Hazards
Some holes due
To active failures
Other holes due to
latent conditions
Losses
Successive layers of defences
Microsystems Exist Within
Other Systems
Patient Selfcare System
Community,
Market, Social
Policy System
Macro
Organization
System
Individual
caregiver, team
and System
Clinical
Microsystem
Navigating the safety space
Increasing
vulnerability
Increasing
resilience
Cultural drivers
Target
zone
Commitment
Cognisance
Competence
Navigational aids
Reactive
outcome
measures
Proactive
process
measures
Safety is a ‘dynamic nonevent’
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‘Dynamic’ because safe outcomes are achieved
through the timely adjustments of skilled human
operators to changes in an uncertain world.
‘Non-event’ because nothing bad happened and
‘normalcy’ does not claim attention.
‘Nothing bad happened yesterday so if I do the
same things today all will be well.’
This only holds true if you really know what
happened yesterday.
Do not erode ‘discretionary energy’ at the sharp end.
Barriers To Achieving Ultra-safe
Healthcare
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Acceptance of limitations on maximum
performance
Abandonment of professional autonomy
Transition from mindset of craftsman to that of an
equivalent actor
Need for system-level arbitration to optimize
safety
Simplify professional rules and regulations
Amalberti R, Berwick D, Barach P. Annals of
Internal Medicine 2005;142:756-764.
Error Management (EM)
Principles
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The best people can make the worst mistakes.
Errors fall into recurrent patterns: error traps
You can’t change the human condition, but you can change
the conditions under which people work
There is no one best way of doing EM
It requires different measures at different levels of the system
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The person
The team
The microsystem/workplace
The organization as a whole.
Mohr J, Barach P. Quality and Safety in Health care 2005.
The TeamSTEPPS Framework
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Knowledge
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Attitudes
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Shared Mental Model
Mutual Trust
Team Orientation
Performance
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Adaptability
Accuracy
Productivity
Efficiency
Safety
Patient Simulators
Lessons learned
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Correct Ergonomic Barriers
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Aim to Reduce Variation through Standardization
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Workspace design: access to necessary equipment and lighting
Equipment: malfunction, inaccessible or difficult to interpret
Lots of expert based tools hard to articulate are used to convey
patient complexity and urgency
Focus on requiring verbal communication & correcting barriers to
achieving this
Importance of a Safety Culture that supports Hand-offs as a
Priority
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Barriers include scheduling issues and fatigue
The hand-off is more than just transfer of content, also the
transfer of professional responsibility
Eminent Need
for Formal Training
Ensure adequate skill levels for complexity of
patient care
 Train teams for effective hand-off
communication:
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 Using
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techniques from other industries
structured language “read-back”
 “Close
the loop” on all hand-off
communications, etc.
Future work
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We are still in the early stages of our work
Continue our research
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Mechanisms of human failures during sign-outs,
Human factors and ergonomic issues that impede the signout process
Perceived risks associated with shift changes by different
classes of providers and administrators
Understanding shared work better
Ultimately, the goal is to identify and implement
interventions that can reduce the risks associated
with transitions in care
Extra Material
Sample of the 14 questions for
nurses and residents
1.
2.
3.
4.
5.
6.
What methods do you use to provide information to the incoming shift
on the patients for whom you have provided care? Of these methods,
which do you prefer, and why?
Do you sometimes find it difficult to communicate with the incoming
shift? If so, what do you feel is the basis for this difficulty?
Can you recall a specific instance or instances where problems arose
in patient care that resulted in part from having received inadequate,
incorrect, or ambiguous information from the outgoing shift? If so, try
to recount the situation.
Do you feel that the experience level, personality, or cultural
background (including language issues) of the provider can impact
the effectiveness of sign-outs? If so, do you have any anecdotal
evidence that you can provide as support for these beliefs?
Have you ever had a discussion or confrontation with a
nurse/resident concerning the way that person conducted a sign-out
procedure? If so, what was the basis for your intervention or
discussion?
In your view, what constitutes an ideal sign-out? Feel free to discuss
any attributes of the sign-out process.
Taxonomy of Sign-out Quality
POOR SIGN-OUT
EFFECTIVE SIGN-OUT
Omissions in Content
Medications or Therapies
Tests or Consults
Medical Problems
Active
Anticipated
Baseline status
Code status
Rationale of primary team
Written Sign-out
Patient Content
Code status
Anticipated problems
Active Problems
Baseline Exam
Pending Test or Consults
Overall Features
Legible
Relevant
Accurate
Up-to-date
Failure-Prone Processes
Lack of Face-to-Face
Communication
Double Sign-out (“Night Float”)
Illegible or Unclear Handwriting
Verbal Sign-out
Face to Face
Anticipate
Pertinent
Thorough
UC Standard Hand-off Protocol:
Progress to Date
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In-service for all program directors conducted Nov 2005
Worked with the following programs to develop discipline-specific
protocols for resident education:
 Obstetrics and gynecology
 Psychiatry
 Pediatrics
 Otolaryngology
 Orthopedic Surgery
 Neurology
 Internal Medicine
 Anesthesia
Presented to UCH Board of Trustees
Protocols distributed at new intern orientation July 2006
Working on continued education and monitoring plan
Understand technical, cultural,
and environmental differences
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Environment
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Culture
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5 programs had a designated hand-off location
3 conducted hand-offs wherever convenient
One resident is a “slave to ‘The List’ [sign-out sheet]” with
“information overload”
In a different program, only acutely ill patients are on sign-ouut
Technical
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All hand-offs use “administrative data” (name, room, etc.)
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Major differences in field-specific content
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Surgical fields: Pre-op consent, post-op checks, etc.
Pediatrics: Custodial issues (DCFS, parents, etc.)
Common use of some language: “If/Then” for contigency planning
Sign-out Process for Neurology
March 17, 2006
Universal pager is
transferred to
on-call Intern
(8 am – 9 am)
Team conducts
rounds (Attending,
PGY4, PGY2)
Transfer of
professional
responsibility
Are there tasks to
be completed?
PGY4 runs the list
with Post-call
Intern
No
Post-call Intern
updates signout on
the computer
Post-call Intern
pages on-call
Intern
Yes
PGY4 assigns
tasks
Verbal
hand-off
Are the tasks
completed?
Post-call Intern runs the
list with oon-call Intern in
the Conference Room
(noon-1 pm)
Yes
Intern reports
status of task to
PGY4 and on-call
intern
No
Input given to PGY4 that
tasks not completed
Unfinished tasks
go to on call intern
Post-call intern
forwards pager to
on-call intern
On-call intern continues
care and follow-up on any
tasks
Keep the focus on patient care:
Clear roles and back-up behavior
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Anesthesia resident to PACU RN
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Interdisciplinary hand-off with challenging complex fastpaced environment
Clear delineation of responsibility to ensure patient
care
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Anesthesia resident to call out for a bed
Unit clerk to respond with bed #
PACU RN to hook up monitors
Equally important back-up behaviors
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Can empower participants to focus on the patient care
“If nursing delay >30 sec, then resident to hook up monitors
and call for RN”
Post Call Sign-out Process for Pediatrics
February 13, 2006
The post call intern updates
sign-out on the computer
(noon – 1p.m.)
Post call intern
brings copy of signout for on call intern
Are there tasks to be
completed? (e.g., f/u labs,
imaging, discharge)
No
Team meets to review list after
noon conference (team includes
other interns, senior residents)
Post-call intern
forwards pager to
on-call intern
Sign-out given to
on-call intern
Post call intern
reports on each
patient
On-call intern continues
care and follow-up on any
tasks
Yes
Sr resident assigns
tasks to other interns
Are the tasks
completed?
Yes
Intern reports
status of task to
senior resident
and on-call intern
No
Sr Resident offers input on
completing task
Tasks
assigned
to others
Unfinished tasks
go to on call intern
“closed-loop”
communication